At Risk Behavior People – Systems - Culture

1. At Risk Behavior People – Systems - Culture Mike Henry September 25, 2002

2. Process Reliability • Process reliability initiatives in place over the years to mitigate process creep and maintain the recipe: • Requirements • Knowledge • Techniques • Equipment/tools • Maintenance • People • Fairly successful, but • One area that requires special attention is mitigating people creep – motivation, mindset, sense of belonging/contributing and ability to use proper judgment • Understand and avoid “at risk behavior” • Significant time and effort spent working to enhance this one area

3. Understanding “At Risk” Behavior • Concern on numerous “unrelated” process/people incidents in the past 12 months • At risk behaviors – examples • Not working to paper (or without paper), taking shortcuts • Not tethering • Not wearing PPE • Continuing to work when confused or distracted • Working short handed • Working when unusually tired or stressed • Not bothering to perform adequate walk downs, pre-ops, checklists, etc.

4. At Risk Behaviors • Not communicating adequately to next shift or supporting group • Improvising and/or using unauthorized tools/materials/ processes • Incorrect lifting or handling • Action taken to understand why people put themselves in “at risk behavior” • Three focus groups formed • Touch labor (operators and inspectors) • First line supervision (operations and quality) • Executive/Senior management • Reviews, interviews, offsite (2 months) • Consensus on root cause and actions

5. General Observations • At risk behavior contributes to most incidents • At risk behavior is the result of: • Poor communication • Unclear roles/responsibilities • Lack of specific experience/training • Confusing procedures • Schedule pressure (self-imposed or system) • Poor preparation/planning • Poor decisions • Bad habits • Peer pressure – pride – self esteem

6. General Observations • At risk behavior, unfortunately, tends to be more in line with human nature • Easier, more convenient, more comfortable, faster than the safe/pre-described method • Reinforced by work culture • Rarely results in negative consequences powerful enough to discourage • Provides more self-satisfaction when completed successfully than following all the rules • Becomes unnoticeable over time (complacency)

7. General Observations • People have good intent, but may also have too much can-do attitude • People using judgment when it appears they have lack of adequate options • Procedures don’t always apply • Help chain non-responsive • Solution seems obvious • Getting job done more rewarding/satisfying/feeling of accomplishment than strict compliance • General frustration due to inability to improve things and/or even be listened to • See painful process for getting things changed • Someone else must often solve operator/inspector problems • Suggestions get lost – not capturing their knowledge

8. General Observations • Leadership not always engaged with “people issues” • Distractions • Physical – fatigue/illness/biological clocks • Mental – repetitious work • Emotional – personal problems • Environmental – over 100° in summer • Attitudes/state of mind • Burned out – lost feeling of contributing • Negative – layoffs/shifts/boss • Caring – no one listens, so why bother • Fear of embarrassment

9. General Observations • System Weaknesses • Change too difficult • Corrective action lacks floor input and follow-up • Too many decisions made in offices/conference rooms • PPIAs could have corrected • Stress from last minute projects • Obvious lack of timely help chain

10. Summary • Summing up root cause of issues • Lack of clear customer-supplier relationship from top–bottom • Lack of timely systems to learn and correct problems • Lose interest to listen and involve operations/inspections • Inadvertently reward wrong behavior • Mistakes • Bad decisions • Missed • opportunities • Weaker PPIAs • System complacency • Reduces workforce ability to: • Be engaged • Always on-guard for disconnects • Motivated to stop and get help • Generate ideas for continuous improvement

11. Challenge • Overall challenge: • Strengthen customer-supplier relationships in all directions and make roles/responsibilities clear • Create an effective and timely help chain • Show leadership interest and support • Will make people: • Feel better about their contributions • Give them confidence to use the system to help them • Help keep them engaged at the right level

12. Recommendations • General recommendation discussion • Enhance understanding of why requirements exist • Recognize operation/inspection process owners • Create clear and timely help chain • Follow-thru on fixes/changes • Enhance engineering-floor relationships • Make operation/inspection roles/expectations clear • Strengthen PPIAs and PFMEAs • Enhance responsiveness of change system • Assure cause and corrective action process involves operations and human element • More management face time • Call off scheduling hounds

13. How to Make it Happen • How to achieve recommendations and meet challenges • Integrated Product Team (IPT) activity (using Integrated Product and Process Development (IPPD) methodology) • Relationships • Help chain • Knowledge sharing • Work Center Change Review Boards (CRB) Program Configuration Control Board (CCB) improvements • Recognize floor as customer • Involve operations • Meet in manufacturing area whenever appropriate • Staff meetings on floor • Propulsion Enterprise System (PES) implementation (Toyota business system) • Strengthen PPIA and PFMEA • Corrective action effectiveness – IPT involvement/on floor/real time, and Corrective Action Board (CAB) reviews • Establish measurements to assess improvement

14. At Risk Behavior – IPT Breadth and Depth Program Team NASA Integration Suppliers (Operators/Inspectors) Hardware Processing Capturing Knowledge IPT Design Intent (DE/ME/QE)